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Showing results for tags 'Just Culture'.
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Content ArticleThe NHS Resolution Just and learning culture charter has been developed as a resource to support the creation of a person-centred workplace that is compassionate, safe and fair when care in the NHS goes wrong. Most of the time, care received by patients in the NHS is safe. Sometimes, even with our best intentions, things can go wrong. When things go wrong, support, care and understanding for everyone involved must be a priority. At no time is there an excuse for incivility, bullying and harassment within the NHS. We accept the evidence that the NHS will provide safer care and be a healthier place to work if we address all of the components of a learning organisation and this underpins our charter. The hope is that this charter will act as a tool to help organisations take a consistent approach towards staff in relation to incidents and errors.
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Content ArticleThe ‘No Blame Culture’ being adopted by the NHS draws attention from individuals and towards systems in the process of understanding an error. This article in the Journal of Applied Philosophy argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. The authors argue that proponents of No Blame Culture often fail to distinguish between blaming someone and holding them responsible, They examine the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, the authors argue that a responsibility culture has significant advantages over a No Blame Culture as it can enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.
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Content Article
A ‘Just Culture’ aims to improve patient safety by looking at the organisational and individual factors that contribute to incidents. It encourages people to speak up about their errors and mistakes so that action can be taken to prevent those errors from being repeated. Adam Tasker and Julia Jones are graduate medical students at Warwick Medical School. They wanted to explore doctors’ perceptions of culture and identify ways to foster a Just Culture, so they conducted a qualitative research study at one of the hospitals where they were doing their medical training. We asked them about why Just Culture is important in the health and care system, and what they discovered from their research. -
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This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Jonathan talks to us about the importance of leadership in creating a safety culture and the role of Patient Safety Learning in fostering collaboration and establishing standards for patient safety. -
Content Article
In this article, published in the Future Healthcare Journal, Helen Hughes, Chief Executive of Patient Safety Learning, reflects on how avoidable harm continues to occur, ten years on from the Francis report into major patient safety failings at Mid Staffordshire NHS Foundation Trust. She describes an implementation gap—where safety concerns and issues highlighted in inquiries and reviews are not being translated into improvements in patient safety. The article outlines some of the key barriers to implementation and suggests what needs to change to ensure we truly learn lessons from patient safety scandals such as Mid Staffordshire. -
Content ArticleA just and learning culture is the balance of fairness, justice, learning–and taking responsibility for actions. It is not about seeking to blame the individuals involved when care in the NHS goes wrong, nor the absence of responsibility and accountability. This report by NHS Resolution aims to promote the value of a person-centred workplace that is compassionate, safe and fair.
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Content ArticleIn this blog, Jennifer Nelson investigates why doctors have one of the highest suicide rates of any profession. She speaks to experts including health psychologist Jodie Eckleberry-Hunt, who highlights that doctors tend to have a lower level of cognitive flexibility, which may affect their ability to cope when things don't go to plan. Psychotherapist Brad Fern goes on to describe the complex range of reasons that doctors may take their own lives, and describes the importance of tackling silence and isolation among doctors. The blog concludes by addressing the need to separate suicide from other wellbeing issues doctors might face, and by looking at how the system itself contributes to high suicide rates.
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Content ArticleThis document by the Joint Commission provides an overview of the issues faced by healthcare workers who are negatively affected by their involvement in a patient safety incident—second victims. It highlights the prevalence of second victims, summarises the key problems they face and outlines recommendations to ensure staff receive adequate support from healthcare organisations when they are involved in an incident.
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News Article
NHS staff to receive ‘air accident’ safety training to reduce patient harm
Patient Safety Learning posted a news article in News
Frontline NHS staff will be given specialist ‘air accident investigation’ style training to help improve the way the health service learns from patient safety incidents. Cranfield University, which has been training air, maritime and rail safety investigators for more than 40 years, is to launch the first intensive course for NHS staff responsible for investigating safety incidents in hospitals. It is part of a growing effort to install a safety science approach to avoidable harm in the NHS, with the service increasingly looking to other industries to adopt new approaches based on the science of human factors and just culture. Traditionally the NHS has focused on simpler investigations that too often miss systemic causes of mistakes and instead target individual nurses and doctors for blame. The new one week intensive course, run in partnership with the charity Baby Lifeline, will start in January and will give students a basic grounding in the science of investigation and using real-life actors and a maternity based scenario, show participants how to get to the real causes of what went wrong. Read full story Source: The Independent, 20 July 2020 -
News ArticleThe former police chief who investigated mental health services in a crisis-hit health board was “shocked” by the poor working relationships and “blame shifting” he uncovered. David Strang, who led the independent inquiry into the issues in NHS Tayside, said staff felt isolated and unsupported and people complained about each other’s practices without coming together to sort the issues out. He described asking staff questions based on information he had received and being met with the response: “Who told you?” He added: “A lot of staff felt there was a real blame culture and that risk and blame fell to the front line.” Read full story (paywalled) Source: 6 February 2020, The Times
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Content ArticleThe Community Pharmacy Patient Safety Group conducted this anonymous survey on patient safety culture in Autumn 2021 and invited pharmacy staff from across the UK to participate. The aim of the survey was to understand patient safety practice from the perspective of frontline pharmacy teams. Both the full results and an infographic of key results are available to download.
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Content Article
Yakob Seman Ahmed, former Director General for Medical services in Ethiopia and the chair of national patient safety task force, and a recent Humphrey fellow, Public Health Policy, at the Virginia Commonwealth University, reflects on Patient Safety Learning's recent report 'Mind the implementation gap: The persistence of avoidable harm in the NHS' and the similar challenges Ethiopia faces in implementing its own standards and policies.- Posted
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Content ArticleThis webpage provides an overview of how human factors affect outcomes in surgical emergencies. It includes: An introduction to human factors Video exploring the case of Elaine Bromiley Explanation of human error and the Swiss Cheese Model Table of factors that reduce human error 'What if?' video showing how simple changes could have resulted in a different outcome in Elaine Bromiley's case Practical tips for managing the paediatric airway in a critically ill child
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Content Article
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In this report, Patient Safety Learning highlights a patient safety implementation gap in the UK that results in the continuation of avoidable harm. It focuses on six specific policy areas where the implementation gap acts as barrier to patient safety improvement and calls for system-wide action in healthcare to transform our approach to learning and safety improvement. It also details six specific recommendations relating to policy areas identified in the report. This article contains a summary of the report, which can be read in full here.- Posted
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Content Article
Safe to speak up? NHS Staff Survey Results 2021
Patient Safety Learning posted an article in Culture
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In this blog, Patient Safety Learning analyses the results of the NHS Staff Survey 2021, specifically focusing on responses relating to reporting, speaking up and acting on safety concerns. It reflects on the importance of staff feeling able to speak up about patient safety incidents and the implications when this is not the case. It describes the NHS’s current approach to creating a patient safety culture and emphasises the need for NHS England and NHS Improvement, in partnership with the National Guardian and Care Quality Commission, to bring forward robust and specific commitments to drive this work forward. -
Content ArticleThis report published by the National Guardian’s Office shows the experience of Freedom to Speak Up Guardians amid the continued pressure of the pandemic on the healthcare sector. Although the majority of guardians who responded to the survey were positive about the culture of their organisation, the results highlight a decline in factors that make it easy for staff to speak up, including support from leadership.
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Content Article
Safety culture discussion cards (Eurocontrol)
Patient Safety Learning posted an article in Good practice
Safety culture has been shown to be a key predictor of safety performance in several industries. It is the difference between a safe organisation and an accident waiting to happen. Thinking and talking about our safety culture is essential for us to understand what we do well, and where we need to improve. These cards from Eurocontrol are designed to help us to do this. -
Content ArticlePromoting a ‘just culture’ is a key theme in patient safety research and policy, reflecting a growing understanding that patients, their families and healthcare staff involved in safety events can experience feelings of sadness, guilt and anger, and need to be treated fairly and sensitively. There is also growing recognition that a ‘blame culture’ discourages openness and learning. However, there are still significant difficulties in listening to and involving patients and families in organisations' responses to safety incidents, and for healthcare staff, a blame culture often persists. This can lead to a sense of sustained unfairness, unresponsiveness and secondary harm. The authors of this article in BMJ Quality & Safety argue that confusion about safety cultures comes in part from a lack of focused attention on the nature and implications of justice in the field of patient safety. They make suggestions about how to open up a conversation about justice in research and practice.
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Content ArticleHealthcare is recognised as a high-risk industry, involving complex systems, vulnerable individuals, and constantly evolving clinical treatments and healthcare products. This is the recording of a webinar hosted by NHS Supply Chain which looked at key patient safety issues in the NHS. It includes examples of learning related to patient safety and assurance priorities for safe healthcare products and services. Speaker panel: Helen Hughes, Chief Executive of Patient Safety Learning Tracey Cammish, NHS Supply Chain Heather Tierney-Moore OBE, NHS Supply Chain Dave Fassam, Healthcare Safety Investigation Branch (HSIB)
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Content ArticleThis article in BMJ Quality and Safety looks back at how the patient safety movement has developed over the last two decades. It argues that although the aim of the movement is to change systems, in reality this has not happened on a wide scale. The authors suggest that if we are to make quantitative improvements to patient safety, the next stage of the patient safety movement needs to prioritise substantive, system-wide change.
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Content ArticleThis systematic review in Nursing Open synthesises the best available evidence on the impact of nurses' safety attitudes on patient outcomes in acute care hospitals. The review included nine studies and found that nurses with positive safety attitudes reported: fewer patient falls and medication errors fewer pressure injuries and healthcare-associated infections fewer mortalities fewer physical restraints and vascular access device reactions higher patient satisfaction. The authors also found that effective teamwork led to a reduction in adverse patient outcomes. They conclude that a positive safety culture results in fewer reported adverse patient outcomes, and that nurse managers can improve nurses' safety attitudes by promoting a non-punitive response to error reporting and promoting effective teamwork and good communication.
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Content ArticleNumerous studies show a link between a positive safety culture (where safety is a shared priority) and improved patient safety within a healthcare organisation. The evidence is so convincing that the US National Patient Safety Foundation (NPSF) lists leadership support for a safety culture as the most important of eight recommendations for achieving patient safety. This overview from the Emergency Care Research Institute (ECRI) provides guidance and recommendations on how to embed approaches to safety culture within healthcare organisations.
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Content ArticleToo often in healthcare, when effective solutions to prevent avoidable harm are found, there is a lack of means to share these more widely. This gap between learning and implementation means that while we may we know what improves patient safety, this information can often remain siloed in specific organisations and health care systems. This results in patients continuing to experience harm from problems that have already been addressed by others. This article published in the Journal of Patient Safety and Risk Management describes how the charity Patient Safety Learning created the hub, a platform to encourage and support shared learning for patient safety. Designed by and for patient safety professionals, clinicians and patients, the hub offers a powerful combination of tools, resources, stories, ideas, case studies and good practice to anyone who wants to make care safer for patients.
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Content Article
'Whistleblowing': a definition for reflection in Speak Up Month
Steve Turner posted an article in Whistle blowing
It's that time again. 'Speak Up Month' in the NHS. In this blog, I discuss the definition of 'whistelblowing' and why this is important. I believe that although the Francis Report has stimulated some positive changes, the only way to successfully move forward on this is to celebrate and promote genuine whistleblowers. This includes using the word 'whistleblowing', not a euphemism. It also needs us to involve everyone, including patients, in the changes. "Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. The more we move away for labelling and stereotyping the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and reconciliation." What is whistleblowing? "In the UK, NHS bodies have been guilty of muddying the waters. Sometimes implying that whistleblowers are people who fail to use the proper channels, or are troublemakers, especially when they go outside their organisation with their concerns. In fact, the Public Interest Disclosure Act makes no distinction between ‘internal’ and ‘external’ whistle-blowers..."- Posted
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Content ArticleThe NHS is in the process of changing the way it embraces patient safety, moving from a focus on individual incidents and issues to a more comprehensive look at system learning. The changes are set out in NHS England/Improvement’s Patient Safety Strategy, released in July 2019 and updated in February 2021. This was followed by the Patient Safety Investigation Framework in March 2020, due for full implementation by Spring 2022. They are important not just in relation to incident management but also because of the implications they have for strategy and board responsibilities in relation to patient safety. So they need careful attention at all levels of NHS organisations. This article from the Good Governance Institute highlights the safety roles and responsibilities of organisations and moving to a proactive approach to safety management.
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